Surgical considerations in the Hartmann's procedure.

BACKGROUND

The present study examines the surgical outcome of the Hartmann's and Hartmann-type procedures, the problems with the remnant rectal stump and the issues related to the colorectal anastomosis as well as the differences in patient outcome.

METHODS

One hundred and five consecutive patients (mean age 66) were evaluated. Surgical morbidity and mortality were analysed with regard to the colorectal pathology and the type of rectal stump remnant. The surviving patients were reviewed according to whether they had second-stage anastomosis.

RESULTS

In 65% of cases there were obstructed or perforated malignancies and in 16% complicated diverticular diseases. The peri-operative mortality and morbidity were 11.4% and 24%, respectively. Seventy-two patients had intraperitoneal rectal stumps and stump blowout occurred in three intraperitoneal and one extraperitoneal remnant stumps. Local tumour recurrence (four) and diversion proctitis (three) were diagnosed in the rectal stump among asymptomatic patients. When the second-stage reversal of Hartmann's procedure was considered (35 cases), twice as many were performed for diverticular and other benign conditions as for tumour cases.

CONCLUSIONS

Although there is a good anatomical basis for advocating extraperitoneal rather than intraperitoneal stumps, in practice the stump blowout rate is not statistically significant (3% vs 4.1%). However, the chances of regaining normal rectal function are much better for benign disease (68% vs 32%--Fisher's exact test, P = 0.004). Complications from second-stage re-anastomosis are not determined by timing of the closure, provided the septic episode has subsided.